Preview Extract
Chapter 74
1. In the event that an unrestrained passenger was injured in a frontal-impact collision, the
nurse should assess for:
6. Paradoxical movement of the chest caused by multiple rib fractures.
7. Unstable pelvic structure causing severe pain on palpation.
8. Unequal pulses in the lower extremities due to possible femur fracture.
9. Neck muscle spasms caused by hyperextension of the neck.
Answer: Paradoxical movement of the chest caused by multiple rib fractures.
Rationale:
If the passenger has no seatbelt or the airbag does not deploy, the body might travel down and
under the steering wheel or over the steering wheel, incurring injury at the body’s point of
impact. Thus, rib fractures are common and can result in flailed chest injuries. Pelvic
fractures are usually a result of frontal-impact collision when a seatbelt is being worn. Femur
fractures may occur when motorcycles are involved in a collision. Hyperextension of the
neck usually occurs in rear-end-impact collisions.
2. If a child is struck by a car, the nurse should assess for:
1. Chest or femur injuries where the bumper may have impacted the child.
2. Liver injuries on the right side due to impact by the vehicle.
3. Lower extremity fracture caused by the wheels running over the child.
4. Kidney injury due to the impact of the vehicle on the lower back.
Answer: Chest or femur injuries where the bumper may have impacted the child.
Rationale:
Children tend to freeze and face the vehicle and therefore end up with more frontal injuries
than adults. So, depending on the height of the child and the height of the vehicle bumper, the
impact occurs on the chest or femur. Adults usually try to escape and turn away from the
vehicle, thus sustaining lateral injuries on the side of impact, such as liver, kidney, or lower
extremity.
3. In addition to lung or heart damage, a stab wound inflicted at or below nipple level may
also cause damage to the:
1. Abdomen.
2. Trachea.
3. Larynx.
4. Urinary bladder.
Answer: Abdomen.
Rationale:
During expiration, the dome of the diaphragm reaches as high as the fifth rib. Stab wounds to
the chest at or below the level of the nipple should be inspected for abdominal injury as well.
The trachea, larynx, and bladder would not be within reach of the typical stab wound
instrument.
4. If a trauma patient arrives in the emergency department (ED) via ambulance, the priority
nursing assessment would include:
1. Airway management with cervical spine immobilization.
2. Insertion of two large-bore IV catheters.
3. Insertion of Foley catheter.
4. Assessing level of consciousness and ability to follow commands.
Answer: Airway management with cervical spine immobilization.
Rationale:
Airway is always priority, with consideration of maintaining the cervical spine in a midline
position. First, the airway is assessed for patency; it may be obstructed by blood,
displacement of tissue, etc.. The other interventions are important as well, but unless tissues
are being oxygenated, death will occur within minutes.
5. For the emergency department client who has external hemorrhage, the most appropriate
way to control the bleeding is for the nurse to:
1. Apply direct manual pressure on the wound.
2. Apply a tourniquet tight enough to stop all the external bleeding.
3. Pack the wound with ice directly on the wound to cause vasoconstriction.
4. Tape ABD pads over the wound and reinforce when they become saturated.
Answer: Apply direct manual pressure on the wound.
Rationale:
Direct pressure is the best and easiest way to control external hemorrhage. A tourniquet can
cause crush injury to tissues and distal ischemia. Ice can cause tissue damage as well.
Applying dressings without compression will not control the bleeding.
6. A trauma client who has experienced a blunt cardiac injury from a steering wheel should be
assessed for cardiac tamponade. Which of the following clinical manifestations would the
nurse be assessing for?
1. Neck vein distention, muffled heart sounds, hypotension
2. Jugular vein distention, bounding pulse, harsh murmur
3. Bilateral upper arm distention, hypertension, edema of the face
4. Absent breath sounds on the left, apical pulse displaced to the left, S3 heart gallop
Answer: Neck vein distention, muffled heart sounds, hypotension
Rationale:
Neck vein distention is caused by elevated central venous pressure, muffled heart sounds is
due to the amount of blood surrounding the heart, and hypotension is due to blood loss (i.e.,
shock). Bounding pulse is usually seen in hypervolemic states.
Bilateral arm distention is usually caused by pressure placed on the superior vena cava, which
is not related to cardiac tamponade. Murmurs are due to valvular disease. Absent breath
sounds are pulmonary problems. A displaced apical pulse is usually a result of hypertrophy of
the heart. S3 gallop is a classic sign of heart failure.
7. The priority NANDA for a hemorrhaging client in the emergency department would be:
1. Ineffective tissue perfusion related to hypovolemia.
2. Impaired ventilation related to airway obstruction.
3. Fluid-volume deficit related to decreased renal perfusion.
4. Ineffective breathing related to shallow respirations.
Answer: Ineffective tissue perfusion related to hypovolemia.
Rationale:
When a client is hemorrhaging, the tissues are not being perfused. Therefore, major organs
such as the heart, brain, and lungs will receive oxygenation, and other organs such as kidneys,
intestines, and long muscles will not receive oxygenation and will become ischemic.
Hemorrhaging relates to arterial and venous perfusion and does not impact ventilation. The
airway is not obstructed, and unless the bleeding is in the lung tissues (which is not
mentioned in this question), breathing will not be impaired initially; therefore, this would not
be a priority NANDA. The hemorrhaging person is losing volume, but it is due to the injury
and actual blood loss rather than renal perfusion.
8. If the trauma client was experiencing pain, the nurse may assess which of the following
objective data?
1. Facial grimacing and change in blood pressure or pulse
2. Flushed skin on neck and face, bradycardia
3. Hyperactive deep tendon reflexes and gripping hands
4. Increased anxiety and verbalizing “impending doom”
Answer: Facial grimacing and change in blood pressure or pulse
Rationale:
Facial grimacing and changes in breathing pattern, blood pressure, and pulse along with
diaphoresis and agitation are objective signs of pain. The patient will be in tachycardia. With
acute pain the deep tendon reflexes will not be affected. Patients with pain have increased
anxiety but usually do not verbalize “impending doom.” Patients experiencing and internal
hemorrhage or a cardiac abnormality many times verbalize “impending doom” comments
such as “I’m going to die.”
9. When monitoring the trauma client’s nutritional status, which of the following data would
be priority to assess?
1. Daily weights and presence of bowel sounds
2. Fluid-volume intake and food allergies
3. Ability to feed self and types of odor in the room
4. Family ability to assist with feedings and last documented bowel movement
Answer: Daily weights and presence of bowel sounds
Rationale:
Assessment of daily weights, 24-hour caloric intake, and presence of bowel sounds, nausea
and vomiting, or flatus are the objective priority data the nurse should assess with regard to
nutritional status. Fluid volume is important but is usually very low in caloric intake and
mainly prescribed for fluid and electrolyte balance. The ability to feed self may be assessing
the client’s neurological and musculoskeletal status. If the client requires rehabilitation, then
family assistance may factor in at that point in the client’s recovery.
10. The trauma client’s spinal cord must be protected from injury. Therefore, the nurse
should:
1. Apply a rigid cervical collar and logroll the client.
2. Keep the client on a backboard for the first 24 hours.
3. Keep the client supine until all diagnostic exams have been completed.
4. Keep the client flat and run a hand underneath to assess for posterior injuries.
Answer: Apply a rigid cervical collar and logroll the client.
Rationale:
For trauma clients, approximately 55% of spinal injuries occur in the cervical region;
therefore, a rigid cervical collar is a must to prevent further injury. Manual stabilization of the
spine is maintained while the client is turned using the logrolling technique. All sources of
bleeding must be ruled out, so the back of the patient must be assessed. Diagnostic exams are
done with lifting help to maintain a stable spine. A backboard is removed shortly after the
client arrives at the emergency department.
11. Which of the following statements is accurate with regard to gerontological consideration
in trauma clients?
1. Older clients have an increased incidence of subdural hematomas since their veins are
more fragile and less elastic when compared to those of younger clients.
2. Younger clients have a thorax that is less compliant and are at a greater risk for developing
rib fractures and flail chest.
3. Older clients have a greater capacity to increase their cardiac output on demand, and
therefore can tolerate greater blood loss than their younger peers.
4. Younger clients have an aorta that is closer to the surface and are at high risk for tears if
their abdomen is struck.
Answer: Older clients have an increased incidence of subdural hematomas since their veins
are more fragile and less elastic when compared to those of younger clients.
Rationale:
Older clients have an increased incidence of subdural hematoma because of the increased
dural vein fragility and loss of elasticity with age. The thorax of the older client is less
compliant and therefore more susceptible to injury. The elderly also are less able to increase
cardiac output on demand due to decreased compliance and a limited degree of compensatory
ability. The aorta of the elderly patient is inelastic and more vulnerable to injury.
12. Upon arrival at the trauma center, which of the following patients is least likely to receive
aggressive fluid resuscitation as an early intervention?
1. The patient with an open abdominal wound from a car accident
2. The patient whose hands were burned in a kitchen fire
3. The patient with a serious head injury from a fall
4. The patient whose leg was severed in an industrial accident
Answer: The patient with an open abdominal wound from a car accident
Rationale:
For a patient who is actively bleeding, increasing the arterial blood pressure through
administration of fluids can dislodge clots and interfere with the hemostatic mechanisms that
manage clotting. Current data suggest that aggressive fluid resuscitation may be useful for
patients with head injuries, thermal injuries, and isolated injury to an extremity.
Test Bank for Timby's Introductory Medical-Surgical Nursing
Loretta A Donnelly-Moreno, Brigitte Moseley
9781975172237, 9781975172268
